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ANEW
EXISTING
PNWS -AW WA BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED
❑ REPLACEMENT
PHONE:
PROPERTY
OWNER:
MAILING
ADDRESS:
, ASSEMBLY
ADDRESS:
❑ R.P.B.A.
SIZE: 1
WATER
PURVEYOR:
ASSEMBLY
LOCATION:
INITIAL
TEST
RESULTS
COMMENTS
REPAIRS
AND /OR
• PARTS
TEST
AFTER
REPAIRS
;mN,PU 'TIGHT ❑ PSID PSID PSID
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS. .
GAUGE CALIBRATION DATE /e /7! DETECTOR METER READING
' TESIBRS
REDUCED PRESSURE ASSEMBLY
a I CHECK • D:O[7BLE: CHECK : AIR
PRESS DROP (A) CHECK #1 INLET
RELIEF VALVE 'f OPENED Al'.
OPENED AT ( B )I TIGHT
MIN 2 PSID
'LEAKED
t
B PSID
= I CHECK #2 PSID
MIN 3'PSI y
RELIEF VALVE _ "� . 'TIGHT , 1
PASS -❑ FAIL ❑ 'LEAKED PSID
REDUCED PRESSURE ASSEMBLY
PRESS DROP
111 CHECK
(A)` CHECK #1
(8) I TIGHT ❑ PSID
!CHECK #2
RELIEF
OPENED
BUFFER
A -B
REPORT RECEIVED BY:
( e/ie(1/
% 5`L 7 $ J' ri/ --)1/ 71 //v_e
Y � o _ 1 - ,. STATE (Ye 1 5q
STREET
D.C.V.A. ❑
R.P.D.A. ❑ D.0 D . ❑ P.V.B.A. ❑ S.V.B.A.. ❑ A.V.B. ❑ AIR GAP
10C1 MAKE: 4/0 MODEL: O(7?
SERIAL / �r
)* 9 R NUMBER: C? �• _ / `3v
• V/1. CP.'..: e / (1A
MIN zPSID
Gene Higgins - BAT
15308 NF. BonlHnn Rd.
Brush Prairie, WA 98606
A & A Drilling, Clackamas, OR
Phone: 503- 284 -3701
(REPRESENTATIVE OF OWNER)
183016
P.V.B.A. / S.V.B.A
DID NOT
OPEN ❑
OPENED AT
CHECK
PRESS DROP
PSID
FAILED
0
P.V.B.A. /S.V.B.A.
PRESS DROP
ZIP
INITIAL ' EST
PASSED
FAILE
SYSTEM
PSI
/
PASSED
DATE:
2j2 , p p
AFTER REPAIRS
DATE:
/
CERTIFICATION NUMBERS
Oregon # 1129
Washington # 0823 -
CCR # 127076
Gauge vu # 1189
, . ,
...
• .
.- 1830b. •-••
1 ._,, •
183014 1
-,- .?:•,4r
i•:. .. , ..
. . . .
-.._::.• . • _
i EXISTING
EXISTING
,
PNWS-AWWA
,.. ,
BACKFLOW ASSEMBLY TEST REPORT 0 REMOVED pNWS A WWk BACKFLOW ASSEMBLY TEST REPORT 0 REMOVED "
-'PROPERTY 0 REPLACEMENT . PROPERTY z. , / El REPLACEME
...
" 01 :
. ,! OWNER: C Ke. e‘ ti, "Pto 1.2PL/C1 PHONE: :' OWNER: ( ' #-'e 4' (../ii atf.A.V PHONE:
.
:!
ADDRESS: 4 : )- CP - 2 - 577 .1 /1 -` 7 4 / 1 71 /ifel■t MAILING / ,.......10., .., ilP7, -, 4/ 4
ADDRESS: ..) (01" /...) --ao
, •
..-------,
CITY / /7(1r-el STATE NZ ZIP
" .CITY...../.4 - Clor7-11-- ---- ZIP STATE .
. ae
:.:...
- , . ... ,
ASSEMBLY
ASSEMBLY . •
:-: ADDRESS: - 7 4 1 ' J-
ADDRESS:
STREET
STREET •
q OR.P.B.A. 0,D.C.V.A. 0 R.P.D.A.,6,D.O.D 0 P.V.B.A. 0 S.V.B.A. 0 A.V.B. 0 AIR GAP •:. OR.P.B.A. la D.C.V.A. 0 R.P.D.A. 6 D.C.D.A. 0 P.V.B.A. 0 S.V.B.A. 0 A.V.B. 0 AIR GAP
SIZE: 1 14 MAKE: ki c ? U f - MODEL- 7 ,- " k) 9 ':=. SIZE: 1 I '1.CA I MAKE: 1 1/ .0 4: - 1 MODEL: 0 1 1 .' "?
.,..
WATER / SERIAL 3 / PURVEYOR: :.WATER ,.,-
'TER ' -.:-...-. ..- ' ' . "/ SERIAL
PURVEYOR: / eq .---- cf NUMBER: / 1 0 0 'A I- d -
.-''.'• ..-/ . / '7 .... _ NUMBER: // z /(
- I-''ASSEMBLY .
ASSEMBLY ;. : ' ' -,./L / ,.. _,/ • ... .
• .
.c: LOCATION: I JO i. / / re 0 A- 4 '0.- -- dr' ;tie W
i'vre alk n'i:LOCATION. f (....:. .! .ce e r .cy&....4 ,;.''...•_, 4 ''.
-' ...
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST ::- : ' - REDUCED PRESSURE ASSEMBLY P.V.B.A. s.v.B.A. INITIAL TEST. -
NI CHECK 1::::DOUBLE. AIR CHECK PASSED
AT p W :. 1.:D.OUBLE:rHECK:':: AIR CHECK
PRESS DROP ! (A )I CHECK 41 INLET FAILED • , : . PRESS PROP (A )1 FAILED
' CHECK 41 , INLET PASSED '
;-.
: - . INITIAL RELIEF VALVE
(B)TIGHT INITIAL RELIEF VALVE A..4 OPENED AT: PRESS DROP DATE
OPENED At I ' IR1 1/,,d E: RESS DROP ,,
TEST DATE: OPENED AT :
MIN 2 PS1D PSID - , : TEST .
ILEAKED MIN 2 PSID (B)ITIGHT
1LEAKE 0 PSID 2 1 /Pg
RESULTS BUFFER .
PSID PSID 2 1 i'l RESULTS • - BUFFER ." : I PSID PSID
. A - B = I CHECK lli
A - B = • - I CHECK 42
,
■ MIN 3 PSI
_PSI , . 1
' ITIGHT )E16. , DID NOT IL SYSTEM DID NOT FAILED SYSTEM
. . RELIEF VALVE
1 P D OPEN 0 0 PSI :. ' ''" ' RELIEF VALVE ITIGHT -
1-, PSID OPEN 0 . El PSI
PASS FAED 0 FAIL 0 ILEAKEDu
0 ' FAIL • 0 . ILEAKE L.,
.. _ ---.,.- •
' / ( e y) f.4 , t" p e , fi.41-- czci
I' .
cOMMENTS
COMMENTS ' " - • -, / -
REPAIRS
7
-;:: REPAIRS : . . , , .
.. AND/OR
AND/OR Y •
= PARTS /
. •
:: •
• //
4
REDUCED PRESSURE ASSEMBLY .
I .. , REDUCED PRESSURE ASSEMBLY P.V.B.A./S.V.B.A. AFTER REPAIRS
, 771 CHECK P.V.B.A./S.V.B.A. AFTER REPARS ,
(A) 1 , : ,,, i . f?ilD 'A;,:..,.:::,...:-.: DATE ' Ill CHECK , A s V7., DATE: •
PRESS DROP :
. ". _ PRESS DROP ""
TEST / CHECK 41
, .
RELIEF — OPENED AT PRESS DROP :TES RELIEF " . I CHECK 41 — OPENED AT PRESS DROP
AFTER OPENED (B) I TIGHT 0 PSID / / .:-1, ', AFTER OPENED (B) TIGHT 0 PSID • 1- /
REPAIRS
BUFFER 1.01 2 PSID ' CHECK 42
PASSED 0 ''', REPAIRS B UFFER lIN ' '
2 1 CHECK 42
A.B=
0
TIGHT 0 PSID —17S13 PSID ::• ' A - B = ma+31=s1 I TIGHT Cl PSID pm PSID PASSED
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE • -
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
f • • RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS. •
:
',.• RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS •
GAUGE CALIBRATION DATE / / METER READING ','": GAUGE CALIBRATION DATES7/it /7PDETECTOR METER READING / l'5
' , TtSTER SIGNATHR Gene Higgins - BAT CERTIFICATION NUMBERS : - •
TESTER STER SIGNATURIT :, . 1 Gene Higgnis - BAT CERTIFICATION NT1MBERS
Oregon
.., - , l 1 15308 NE Bonanza Rd. Oregon # 1129
-
TESTERS NAM • • 11 15308 NE Bonanza Rd.
:=.- TESTERS NAM 7 P • 7 D 1 Washington # 0823
, Bnish Prairie, WA 98606
'... ....e
—
Brush Prairie, WA 98606 Washington # 0823 ' ,
TESTERS ADDRESS
A & A Drilling m
, Clackaas, OR CCB # 127076 ,.. TEsTERsAooks s . I A & A 1/Filling, Clackamas, OR CCB # 127076
COMPANY NAME
Phone: 503-284-3701 Gauge # 1189
Phone 5
: 03-284-3701 . Gauge #1189 !:. COMPANY NAME \
1 SERVICE. RESTORED • 0 SERVICE RESTORED
. REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) REPORT RECEIVED BY: .. • (REPRESENTATIVE OF OWNER) •
74 : .
WHTTE - Water System COPY PINK-Cusmmern,,,,,